Life.Love.

Laughter

Dr Farid Sura W, Sp U

Program Studi Urologi

FACTS OF MALE INFERTILITY
• 15% of all couples globally = infertile
• Male Partner contributing = 50% cases
• Known causes  may have a medical option
• Majority = Idiopathic, Tx should be
empiric or directed towards optimization
• Immediate ART (IVF & ICSI) is not a
cost-effective Tx for male factor infertility
 Improve sperm quality first (IUI)

Agarwal A. et al; A unique view on male infertility around the globe, Reprod Biol Endocrinol. 2015; 13:37; Dabaja & Schlegel. Medical treatment of male infertility. Transl Androl Urol.
2014 Mar; 3(1): 9–16; (2) Naz & Kamal, 2017. Classification, causes, diagnosis and treatment of male infertility : a review. Orient Pharm Exp Med ; 17:89 – 109.; (3) Isidori, A. Medical
Treatment to Improve Sperm Quality. 2006. Reproductive BioMedicine Online (RBMO). Vol. 12 No 6, 2006.

Program Studi Urologi

CAUSES OF MALE INFERTILITY
Associated factors of 12945 patients:

7%
9%
2%
2%
4%
33%
2%

8%
3%
16%
13%

EAU Guidelines on Male Infertility 2015, Andrology, In: Nieschlag E, Behre HM and Nieschlag S (eds). Male reproductive
Program Studi Urologi
health and dysfunction, in Male reproductive health and dysfunction. 2010, Springer Verlag: Berlin.
 OXIDATIVE STRESS

Majzoub A, Agarwal A. Antioxidant therapy in idiopathic oligoasthenoteratozoospermia. Indian journal of urology: IJU: journal of the Urological Society of India. 2017 Jul;33(3):207.

Program Studi Urologi

DNA Fragmentation
& Male Infertility

Program Studi Urologi

DNA FRAGMENTATION
• Spermatozoa are highly specialized cells
to deliver an intact paternal genome to
the oocyte.
• DNA fragmentation is the presence of
DNA breaks.
• Some research discovered that high
levels of sperm DNA fragmentation
(sDF) can be found in spermatozoa of
sub/infertile men..

1. Zini and Argawal. 2018. A Clinician’s Guide to Sperm DNA and Chromatin Damage . Springer International Publishing. New Zealand. ISBN 978-3-319-71815-6. https://doi.org/10.1007/978-3-319-71815-6
2. Muratori et al. Sperm DNA Fragmentation : Mechanisms of Origin. Springer Nature Switzerland AG 2019. https://doi.org/10.1007/978-3-030-21664-1_5

Program Studi Urologi

DNA FRAGMENTATION
• About 50% of all cases  underlying cause for a pathological semen analysis cannot be found.

• In addition, in about 15% of all couples with subfertility/infertility caused by male factors, standard semen analysis
does not reveal abnormalities.

• One of the reasons may be related to sperm DNA integrity.

• Recent studies have shown that DNA integrity plays an important role during fertilization and early pregnancy.

• DNA damage can be caused by intrinsic (e.g. pathological maturation of sperm cells, oxidative stress) or extrinsic
factors (e.g. varicoceles, infections or advanced age).

Park YS, Lee SH, Choi HW, Lee HS, Lee JS, Seo JT. Abnormal human sperm parameters contribute to sperm DNA fragmentation in men with varicocele. World J Mens Health. 2018;36(3):239–47.

Agarwal A, Allamaneni SS. Sperm DNA damage assessment: a test whose time has come. Fertil Steril. 2005;84(4):850–3.

González-Marin C, Gosálvez J, Roy R. Types, causes detection andrepair of DNA fragmentation in animal and human sperm cells. Int J Mol Sci. 2012;13(11):14026–52.

Program Studi Urologi

HOW TO MEASURE DNA INTEGRITY?
1. Sperm-Hyaluronan Binding Assay (SHBA).
• Indirectly tests DNA integrity
• a method based on the premise that only fully developed mature sperm cells with high
DNA integrity have the ability to bind to hyaluronic acid, which simulates the human
pellucid zone.

2. Sperm Chromatin Dispersion (SCD)

• Proven to be an effective tool to directly assess DNA integrity.
• This test detects the ability of the sperm chromatin to disperse, following acid
denaturation and removal of nuclear proteins.
Lipovac M, Bodner F, Schütz A, Kurz H, Riedel C, Mair J, Imhof M. Increased Hyaluronan acid binding ability of spermatozoa indicating a better maturity, morphology
and higher DNA integrity after micronutrient supplementation. EMJ Urol. 2014;1:60–5.

Zhang LH, Qiu Y, Wang KH, Wang Q, Tao G, Wang LG. Measurement of sperm DNA fragmentation using bright-field microscopy: comparison between sperm chromatin
dispersion test and terminal uridine nick-end labeling assay. Fertil Steril. 2009;94(3): 1027–32.

Program Studi Urologi

 DNA Fragmentation Index
(DFI)
• The degree of DNA integrity is determined by the DNA fragmentation
index (DFI).

• The DFI is the percentage of sperm cells with DNA damage.

• A DFI value above 15% is commonly understood to be pathologic and

is associated with subfertility/infertility.
– However, so far 15% is only a threshold that still warrants more research.
Fernández JL, Muriel L, Rivero MT, Goyanes V, Vazquez R, Alvarez JG. The sperm chromatin dispersion test: a simple method for the determination of sperm DNA fragmentation. J
Androl. 2003;24(1):59–66.

Lipovac M, Bodner F, Schütz A, Kurz H, Riedel C, Mair J, Imhof M. Increased Hyaluronan acid binding ability of spermatozoa indicating a better maturity, morphology and higher DNA
integrity after micronutrient supplementation. EMJ Urol. 2014;1:60–5.

Program Studi Urologi

Increased Sperm DNA Fragmentation (sDF)
Significantly Increases Number of
Miscarriages
• Sperm DNA fragmentation is
significantly higher in couples
with unexplained recurrent
pregnancy loss than in fertile
men.
• Absalan et al. J Assist Reprod
Genet 2012;29(1):11-14
• Khadem et al. Adrologia
2014;46(2):126-130.

• High levels of sperm DNA

fragmentation have a
significant negative effect on
clinical pregnancy following IVF
and/or ICSI treatment.
Carlini et al. Reprod Biomed Online. 2017 Jan;34(1):58-65).
• Simon et al. Asian J Androl. 2017
Jan-Feb;19(1):80-90.

Program Studi Urologi

DNA Fragmentation: Correlation with Embryo Development, Lower
Implantation Rate and Miscarriage Rate

• In 2019, Borges et al reported that higher SDF is correlated with poor embryo
development, lower implantation rate, and higher miscarriage rate in non-male
factor infertility ICSI cycles.
• Based on the prospective cohort study of 475 cycles of IVF, he concluded that
SDF test can bring additional information to sperm quality evaluation of men

Borges et al. 2019. Sperm DNA fragmentation is correlated with poor embryo development, lower implantation rate, and higher
miscarriage rate in reproductive cycles of non-male factor infertility. Fertility and Sterility Vol 112. No 3.
https://doi.org/10.1016/j.fertnstert.2019.04.029 Program Studi Urologi
ASRM Recommendation Guideline on
DNA Fragmentation Testing (2013)
Summary of Recomendation
There is a fair evidence (Level B) that increased DNA Fragmentation is associated with
reduced fertility; however, there is insuficient evidence (Level C) to use the test as a
predictor of fertility since cut-points have not been clearly established and validated.
There is insufficient evidence (Level C) to recommend the use of DNA integrity tests
to predict pregnancy with IUI
There is insuficient evidence (Level C) to recommend routine use of DNA integrity
testing for patients undergoing IVF
There is insufficient evidence (Level C) to recommend routine DNA Integrity Testing
for Patients undergoing IVF/ICSI
The is insufficient evidence (Level C) to recommend routine DNA Integrity testing to
predict pregnancy Loss

ASRM 2013. The Clinical Utility of Sperm DNA Integrity Testing : a guideline. Fertil Steril 2013 by American Socirty for Reproductive Medicine. https://dx.doi.org/10.1016/j.fertnstert.2012.12.049

Program Studi Urologi

 New Research Keep Coming Reporting the
Function of sDF Testing

• Breznik et al analyze the correlation

of sDF test, hyaluronan-binding
ability and hyperactivation to the
Fertilization rate (FR) and Embryo
Quality (EQ) after IVF and ICSI
• From a prospective data of 133
couples, they concluded that
Halosperm test, HA test and induced
hyperactivity are useful in predicting
the ability of spermatozoa to fertilize
oocytes in IVF and might help
clinician distinguish semen samples
suitable for IVF or ICSI

Breznik et al. 2013. Are Sperm DNA fragmentation, hyperactivation, and hyaluronan-binding ability predictive for fertilization and embryo development in in vitro fertilization and intracytoplasmic sperm
injection?. Fertility and Sterility Vol 99 No 5. ASRM Published by Elsevier. http://dx.doi.org/10.1016/j.fertnstert.2012.11.048

Program Studi Urologi

sDF as A Predictive Parameters in the Outcomes of
ART Cycles in Women with Reduced Ovarian
Reserve (ROR)
• From a total 2,865 of first cycle of IVF or ICSI, the researcher reported that SDF above 27.3% might
negatively impact the live-birth and implantation rates in the ROR Group but not in the NOR (normal
Ovarian reserved) group.
• However, this retrospective data also reported that SDF above 27,3% significantly increased the risk of
early abortion in the NOR group

Jin et al. 2015. Effect of sperm DNA fragmentation on the clinical outcomes for in vitro fertilization and intracytoplasmic sperm injection in women with different ovarian reserves. Fertil
Steril 2013; 103:910-6. http://dx.doi.org/10.1016/j.fertnstert.2015.01.014

Program Studi Urologi

 Lifestyle Modifications

• Avoid excess
radiation and
heat
• Quit Smoking
and Limit
Alcohol Drink
• Exercise
regularly and
keep healthy
BMI
• Wear loose
clothing

Kim, Gi Young. 2018. What Should be done for men with sperm DNA Fragmentation. Clin Exp Reprod Med 2018; 45(3):101-109. https://doi.org/10/5653/cerm.2018.45.3.101

Program Studi Urologi

Varicocele Repair
• Higher levels of SDF were observed in patients with
varicocele.
• Elevated levels of ROS damage both nuclear and
mitochondrial DNA causing base modifications, strand
breaks, and chromatin cross=links as well as increasing
sperm DNA Damage
• Surgical repair improved semen parameters and was
more cost-effective than IVF/ICSI
Kim, Gi Young. 2018. What Should be done for men with sperm DNA
Fragmentation. Clin Exp Reprod Med 2018; 45(3):101-109.
https://doi.org/10/5653/cerm.2018.45.3.101

Program Studi Urologi

 2019 DNA study: Micronutrient & Lifestyle
Modification can Decrease Sperm DNA
Fragmentation
• Subfertile man  found that in patients with
DFI>15%, both lifestyle modification and
micronutrients treatment can decreased the sperm
DNA fragmentation (SDC assay) after three months 20.8420.55
10.5414.48
10.16 9.76
3.67 8.82

• However, in larger sample (n=306) that analyzed

patients without considering the DFI Value,
treatment groups displayed a better improvement
compared to lifestyle modification (control groups)

• (the treatment groups = combination of eight Initial After 3 Month

micronutrients + lifestyle modifications whereas
there were only lifestyle modifications in control
groups)

Eidenberget et al. 2019. Measured with Sperm Chromatin Dispersion (SCD) Technique : Will DNA Integrity in Spermatozoa Increase After Micronutrient Supplementation?
Comparative Controlled Study. Fertility & Reproduction. Vol 1 No 3. Sept 2019, 136-140. doi: 10.1142/S2661318219500142

Program Studi Urologi

• Trace elements, vitamins and amino acids are important for DNA synthesis
and spermatogenesis, antioxidant therapy seems a promising option for the
improvement of cell integrity.

• Positive effects of micronutrients on fertility have already been discussed

in various studies.

• Therefore, it is obvious that a combination of micronutrients can have a

significant influence on sperm quality and pregnancy outcome.
Showell MG, Mackenzie-Proctor R, Brown J, Yazdani A, Stankiewicz MT, Hart RJ. Antioxidants for male subfertility. Cochrane Database Syst Rev. 2011;(1):CD007411.

Lipovac M, Bodner F, Schütz A, Kurz H, Riedel C, Mair J, Imhof M. Increased Hyaluronan acid binding ability of spermatozoa indicating a better maturity, morphology and
higher DNA integrity after micronutrient supplementation. EMJ Urol. 2014;1:60–5.

Program Studi Urologi

 FORMULA OF 8 MICRONUTRIENTS to
improve SDF
Micronutrient Purposed Mechanisms
Ingredients
L-Carnitine “Radical catcher” Enhance sperm energy production therefore, better sperm motility. A
study also showed improvement in sperm concentration 1
L-Arginine Improve sperm motility/vitality in infertile men and in sperm motility in in vitro2

Glutathione Antioxidant with hydroperoxides reduction pathway.

It also enhance sperm motility and morphology 1
Coenzyme Q10 Endogenously found inside the sperm. A cofactor in electron transport and involved
in cellular respiration hence sperm motility. A study showed an increase in motility
from 9% to 16%1; improves FSH/LH
Folic Acid Required in DNA synthesis pathway, hence proposed in spermatogenesis 2 ;
reduces free radicals from round cells
Selenium Reduces oxidative stress; Essential trace elements that plays and important role
in sperm formation and testosterone synthesis3
Zinc Plays pivotal role in testicular development, steroidogenesis, synthesis and secretion of LH
and FSH, formation and maturation of spermatozoa3
Vitamin E Fat soluble antioxidant, prevents lipid peroxidation and enhances function of
other antioxidants3

1) Kumar R, Gautam G & Gupta NP. 2006. Drug Therapy for Idiopathic Male Infertility : Rationale Versus Evidence. The Journal of Urology by Ameracan Urological Association. Vol 176, 1307-1312. 2) Lipovac M et al. Comparison of the effect of a combination of eight micronutrients versus a standard mono preparation on
sperm parameters. Reproductive Biology and Endocrinology. 2016;14(1):84. 3) Alahmar AT. 2018. The effects of oral antioxidants on the semen of men with idiophatic oligoasthenoteratozoospermia. Clinical Exp Reproductive Medicine (CERM) 45 (2): 57-66

Program Studi Urologi

SYNERGISTIC EFFECT OF 8
MICRONUTRIENTS

Program Studi Urologi

6 CLINICAL STUDIES OF THE
FORMULA

Program Studi Urologi

 says….
• Lifestyle modification should be considered in patients with idiopathic male infertility

• Clomiphene citrate and tamoxifen have been widely used in idiopathic OAT: a meta-analysis
reported some improvement in sperm quality and spontaneous pregnancy rates.

• Men taking oral antioxidants had an associated significant increase in sperm parameters and in
live birth rates in IVF patients in a Cochrane analysis.

• Concerning natural conception the role of antioxidants needs further investigations.

Salas-Huetos, A., et al. Dietary patterns, foods and nutrients in male fertility parameters and fecundability: a systematic review of observational studies. Hum Reprod Update, 2017. 23:
371.

Chua, M.E., et al. Revisiting oestrogen antagonists (clomiphene or tamoxifen) as medical empiric therapy for idiopathic male infertility: a meta-analysis. Andrology, 2013. 1: 749.

Imamovic Kumalic, S., et al. Review of clinical trials on effects of oral antioxidants on basic semen and other parameters in idiopathic oligoasthenoteratozoospermia. [Review]. BioMed
Research International, 2014. 426951.

Showell, M.G., et al. Antioxidants for male subfertility. The Cochrane database of systematic reviews, 2014. 12: CD007411.

Ross, C., et al. A systematic review of the effect of oral antioxidants on male infertility. Reprod Biomed Online, 2010. 20: 711.

Program Studi Urologi

• TAKE HOME MESSAGES
 Male infertility prevalence is increasing and contributing
up to 50% in couple infertility cases
 Sperm DNA Fragmentation is highly correlated
with miscarriage and recurrent pregnancy loss
 Combination of 8 micronutrients is proven to
improve SDF
 The formula of 8 micronutrients is the only formula that
proven by 6 clinical studies to improve sperms quality &
reduce DNA Fragmentation.

Program Studi Urologi